Dual Eligible Demonstrations (U.S. Medicare/Medicaid): Resources for Advocates - The Commonwealth Fund

Dual Eligible Demonstrations: Resources for Advocates - The Commonwealth Fund

Overview

In April 2011, the Centers for Medicare and Medicaid Services (CMS) awarded $1 million grants to 15 states for the design of integrated service delivery and payment models for dual eligibles, people with high health care needs who are enrolled in both Medicare and Medicaid. CMS has emphasized that consumer stakeholders must be included in the planning processes. A new Commonwealth Fund–supported Web site, http://dualsdemoadvocacy.org/, offers educational resources for consumer groups and can serve as a platform for sharing ideas and strategies for improving care for dual eligibles.

The Problem

States are struggling to find ways to engage consumers in the development of integrated models of care for people with Medicare and Medicaid. At the same time, consumer representatives say they need resources to help them gain a better grasp of the technical design and implementation issues involved.

Audience

Health care consumers and state consumer advocates

The Intervention

The Web site http://dualsdemoadvocacy.org/ is a resource for consumers and advocates that provides background information, links to news and events, and, in the Advocate Tools section, concrete recommendations to help advocates work with state policymakers to ensure that new delivery models improve care for dual eligibles. The Advocate Tools cover such topics as the development of the appeals process if health plans or providers deny needed care; patient assessment and care planning; consumer protections; and provider payment models. The site also offers state-by-state information about the dual eligibles population and the demonstration projects that local policymakers are considering. The site also features a custom search tool to direct users to the most valuable resources on the Web about dual eligibles..

For More Information

Visit http://dualsdemoadvocacy.org/.

The Medicare NewsGroup introduces new website for journalists

The Medicare NewsGroup introduces new website for journalists

Quest, Lab Corp. Fall (financial) After Fraud Whistle-Blower Interview - Bloomberg

Quest, Lab Corp. Fall After Fraud Whistle-Blower Interview - Bloomberg

Countering the Misincentivization of Cancer Medicine by Real-Time Personal Professional Education (febrile neutropenia medications)

Countering the Misincentivization of Cancer Medicine by Real-Time Personal Professional Education [Cancer Center Business Summit]:

Purpose:
In the United States, public and private payer misincentivization of medical care and the invisibility of costs to the consumers of that care have conspired to create unsustainable growth in health care expenditure that undermines our economy, diminishes our productivity, and limits our international competitiveness. Cancer medicine provides a small yet salient example. On average, Medicare reimburses oncologists 6% above the average acquisition price for essential anticancer agents and supportive therapies. The costs of these agents vary across a stunning five orders of magnitude, from a few dollars to more than $400,000 per course of treatment. The profitability to providers varies across approximately four orders of magnitude, from cents to thousands of dollars per treatment. National guidelines (National Comprehensive Cancer Network [NCCN], American Society of Clinical Oncology [ASCO]) help providers select the most effective therapies without regard for cost.

Methods:
We created an oncologist-to-oncologist professional education program to help cancer physicians optimally use expensive long-acting white blood cell growth factors, in accordance with these national guidelines.

Disparities in hospice care among older women (over 65 yrs) dying with ovarian cancer

Disparities in hospice care among older women dying with ovarian cancer:

Background
Timely hospice referral is an essential component of quality end-of-life care, although a growing body of research suggests that for patients with various types of cancer, hospice referrals often occur very late in the course of care, and are marked by sociodemographic disparities. However, little is known about the ovarian cancer patient population specifically. We examined the extent and timing of hospice referrals in ovarian cancer patients over age 65, and the factors associated with these outcomes.

Methods
We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify 8211 women aged 66+ with ovarian cancer who were diagnosed between 2001 and 2005 and died by December 31, 2007. We excluded women who were not eligible for Medicare A continuously during the 6 months prior to death. Outcomes studied included overall hospice use in the last 6months of life and late hospice enrollment, defined as within 3 days of death. We examined variations in these two measures based on year of diagnosis and sociodemographic characteristics (age, race, marital status, rural residence, income, education) and type of Medicare received (fee-for-service vs. managed care).

Results 
Among 8211 women in the cohort who died from ovarian cancer, 39.7% never received hospice care (3257/8211). Overall hospice care increased over the period of observation, from 49.7% in 2001 to 74.9% in 2005, but the proportion of women receiving hospice care within 3days of death did not improve. Among those who received hospice care, 11.2% (556/4954) and 26.2% (1299/4954) received such care within 3 and 7 days of death, respectively. A higher proportion of black women (46.5% vs. 38.4% among whites), women in the lowest income group (42.8% vs. 37.0% in the highest income group), and those receiving fee-for-service Medicare (41.3% vs.33.5% for women in managed care) never received hospice care. In multivariable models, factors associated with lack of hospice care included age younger than 80 years (OR 1.27, 95% CI 1.15–1.40), non-white race (OR 1.44, 95% CI 1.26–1.65), low income (OR 1.17, 95% CI 1.04–1.32) and enrollment in fee-for-service Medicare compared with managed care (OR 1.39, 95% CI 1.24–1.56).

Conclusion 
More older women with ovarian cancer are receiving hospice care over time, however, a substantial proportion receive such care very near death, and sociodemographic disparities in hospice care exist. Our data also support the need to target lower-income and minority women in efforts to increase optimally timed hospice referrals in this population. Our finding that ovarian cancer patients enrolled in managed care plans were more likely to receive hospice care suggests the importance of health care system factors in the utilization of hospice services.

AMA Approves Vermillion MAAA Category 1 Code for OVA1; Will it Improve Reimbursement? GenomeWeb (Medicare)

"Medicare reimbursement has been a point of concern for the company. As previously covered in PGx Reporter sister publication ProteoMonitor, there have been reports that Medicare has been denying OVA1 claims at a rate of more than 80 percent (PM 12/23/2011)."

Canadian Doctors for Medicare: Neat, Plausible and Wrong: The Myth of Health Care Unsustainability

Neat, Plausible and Wrong: The Myth of Health Care Unsustainability

The “Sustainability” Myth The assertion that Medicare is “unsustainable” has been repeated so many times[1] that in some circles it has become accepted as indisputable fact. Critics[2] of...
[+] Read full story

Perspective: Medicare Advantage — Lessons for Medicare's Future — NEJM

Medicare Advantage — Lessons for Medicare's Future — NEJM

The Medicare Advantage Success Story — Looking beyond the Cost Difference

The Medicare Advantage Success Story — Looking beyond the Cost Difference: New England Journal of Medicine Ahead of Print.

U.S. Medicare - Study calls CMS' CT scan measure inaccurate - Healthcare business news and research | Modern Healthcare

A study in the Annals of Emergency Medicine concludes that a new imaging efficiency measure from the CMS known as OP-15 is not accurate in determining which hospitals perform CT scans under appropriate circumstances.

Physician Guilty of Medicare Fraud Put Patients at Risk - Trampling the Hippocratic Oath "On the Way to the Bank"

Tory Silence On Medicare Pledge “Deafening” - Health Care Pledge Supported By All Parties, But One (Harper) note: finance minister Jim Flaherty a 'no response'

Tory Silence On Medicare Pledge “Deafening”
Health Care Pledge Supported By All Parties, But One

TORONTO ‐ Stephen Harper’s decision to refuse even the most basic commitment to Medicare has caused surprise and concern among Canadians who care about our health care system. Hundreds of local candidates representing the Liberal, New Democratic and Green Parties, and all three of their National Leaders, have given their support to the Health Care Protection Pledge, a commitment to sustain Medicare past the 2014 Health Accord negotiations. Stephen Harper is the only national leader who has chosen not to express support for our health care system, and all but two Conservative candidates have followed his lead, almost universally refusing to make a commitment to Medicare....cont'd

Commentary MJA Insight: Henry Woo: Abuse of self-pay patient system widespread (ethics)

Note: sound familiar? 
(to view subscribe(free)

"....Sadly, the abuse of the self-pay system is widespread in the NSW public hospital system. We may be aware that it is happening, but nothing will change unless patients complain, and this is hardly likely.

Surgeons who aren’t happy with this arrangement appear unwilling to come forward in fear of political retribution, professional isolation and stymied career progression.

If we were to abolish self-pay, would we risk throwing the baby out with the bathwater? We have to balance the risks to our professional standing, our inability to regulate this behaviour and the financial risks to those who can least afford it against the risk of removing patient choice.

I would like to see this practice abolished, but if we cannot speak out about this when it involves unethical behaviour, the balance is heavily tilted against ever eradicating the self-pay system in our public hospitals."

Canadian Doctors for Medicare - Defending (Canadian) Medicare

Canadian Doctors for Medicare advocates for the maintenance and improvement of Canada's universal, single-payer health care system. ...

Canada - Fraser Institute:The Dollar Cost of Medicare | Fraser Institute

The Dollar Cost of Medicare
Appeared in the New Brunswick Telegraph Journal
Authors:	Nadeem Esmail
Release Date:	November 16, 2010
The true cost of Medicare for individuals and families in Canada is often misunderstood, with many people thinking it’s either free or covered by our provincial health insurance premiums....cont\d

Donald Berwick takes charge of Medicare and Medicaid : The Lancet

Berwick's Institute for Healthcare Improvement (IHI) developed programmes in the US and around the world that focused on improved delivery systems. Among the group's innovations is the “100 000 Lives” campaign, which challenged hospitals to reduce medical errors. Altman said the programme “almost single handedly” changed attitudes among hospital administrators towards a focus on patient safety.

(U.S.) Do Insurers Have to Pay for Colonoscopy Now? - Prescriptions Blog - NYTimes.com

Obama Chooses Health Policy Scholar as the Director for Medicare and Medicaid - NYTimes.com

Note: I have met Dr Berwick (via WHO Patient Safety), an extraordinarily compassionate individual

"WASHINGTON — President Obama will soon name Dr. Donald M. Berwick, an iconoclastic scholar of health policy, to run Medicare and Medicaid, the programs that serve nearly one-third of all Americans, administration officials said Saturday.

Dr. Berwick, a pediatrician, is president of the Institute for Healthcare Improvement in Cambridge, Mass. He has repeatedly challenged doctors and hospitals to provide better care at a lower cost...."

"Dr. Berwick has denounced “the insanity of health care that costs too much and achieves too little.” But at the same time, he celebrates the work of hospitals that have reduced medical errors and deaths by the systematic application of proven techniques. And he wants to disseminate the secrets of communities that provide high-quality care at low cost."

Medicare Establishes Reimbursement Coverage for Vermillion's OVA1(TM) Test - financial news

"FREMONT, Calif., March 12, 2010 /PRNewswire via COMTEX/ -- Vermillion, Inc. (Pink Sheets: VRML) today announced that Medicare will cover OVA1(TM), a test to help assess the likelihood that an ovarian mass is benign or malignant. Highmark Medicare Services is the CMS contractor that will process Medicare claims for OVA1. Yesterday Highmark announced its decision to cover this new service....."